DEPRESSION

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DEPRESSION
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What Does Depression Feel Like?

• Lost, in a dark tunnel, hopeless, doomed, dying
• Empty, nothingness, blank, no feelings, dead
• No energy, tired, heavy, paralyzed
• Afraid, vulnerable, defenseless
• Unlovable, worthless, useless, stupid
• Guilty, evil, contaminated
• Suffering, miserable, in unrelenting emotional
  pain

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Incidence and Prevalence

• NIMH --Depression Rate
• 7.1 in women/Postpartum Depression
• 3.5 in men
• 7 of US adult population in a given year
• Age of onset- any time, highest in 20s
• Highest Prevalence-ages 25-44.
• General Hospital admits 10 to 15 are depressed
• See Box 29-3 p. 380- 5th ed.
• Facts p. 272- 6th ed.

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Many Forms of Depression
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SELECTED DISORDERS

• DSM IV-TR Depressive Disorders
• Major Depressive Disorder (MDD)
• (several subcategories or specifiers)
• Dysthymia
• Depressive Disorder, Not Otherwise Specified
  (NOS)
• Has characteristics of depression but does not
  fit exact criteria for the above

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Criteria for Major Depressive Disorder

• 5 of the following 9 Symptoms gt 2 weeks
• Depressed Mood
• Anhedonia (or Apathy)
• Significant change in weight
• Insomnia or hypersomnia
• Increased or decreased psychomotor activity
• Fatigue or energy loss
• Feelings of worthlessness or guilt
• Diminished concentration or indecisiveness
• Recurrent death or suicidal thoughts

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Symptoms of Major Depressive Disorder

• One of the of the criteria must be
• Depressed Mood
• Anhedonia (or Apathy)

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Dysthymic Disorder

• Chronic disorder
• Depressed mood at least 2 years for more days
  than not (gt50 of the time)
• 2 or more of the following
• Poor appetite or overeating
• Insomnia or hypersomnia
• Fatigue or low energy
• Low self-esteem
• Poor concentration
• Feelings of hopelessness
• Never free of symptoms for 2 months

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What Does Depression Look Like?
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Symptoms of Depression

• Alterations in Activity
• Psychomotor agitation
• Tired (fatigue)
• Poverty of speech
• Poor hygiene
• Weight loss or gain
• Insomnia or hypersomnia
• Altered Social Interactions
• Poor social skills
• Withdrawn, prefer isolation

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Symptoms

• Alterations of Cognition
• Inability to concentrate
• Confusion
• Easily distracted
• Problems with thinking ideas and problem solving
• Uninterrupted self-defeating ruminations
• Alterations of Affect
• Low-self esteem
• Worthlessness
• Guilt
• Anxiety
• Hopelessness

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Symptoms

• Alterations of a Physical Nature
• Somatic Complaints
• Preoccupation with their bodies
• Panic Attacks in 15 to 30 of people with MDD

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Symptoms of Depression

• Alterations of Perception
• Usually Mood Congruent
• Hallucinations
• Voices accusing or blaming of self
• Delusions (really, these are cognitive
  alterations!)
• Delusion of Persecution
• e.g. For a moral or ethical mistake
• Somatic Delusions
• e.g. I am full of cancer

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Depression Model and Theories

• Unified Model of Mood Disorders
• Genetic Vulnerability
• Developmental Events
• Physiological Stressors
• Psychosocial Stressors
• Any of these can start the cycle of disturbed
  neurochemistry

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Neurochemical Theories

• Serotonin and Norepinephrine
• Level is altered at the receptor site
• Receptor sensitivity changes
• The cells they activate have lost the capacity to
  respond

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Genetic Theories

• Depression - major correlation, but not clear
• Two thirds of twins are concordant for MDD if one
  or both parents have MDD

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Endocrine Theory

• Elevated levels of corticotropin-releasing
  hormone
• Elevated pituitary release of andreno-corticotropi
  c hormone
• Early life exposure to overwhelming trauma

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Circadian Rhythm Theory

• Medications
• Nutritional deficiencies
• Physical illness
• Wake-sleep cycles
• Hormonal fluctuations

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Psychosocial Perspectives

• Freud believed depression was anger turned on the
  self overactive superego
• Sullivan-problems in the interpersonal areas of
  neglect, abuse, rejection, loss
• Cognitive theories
• Beck-Depression based on distorted thinking
  patterns
• Ellis-Concept of negative self-talk and
  catastrophising

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Beck Depression Inventory Assesses severity of
depressive symptoms
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Psychosocial Perspectives, contd.

• Behavioral Theories- The way you act affects
  peoples response
• Seligman- Developed theory of learned
  helplessness, hopelessness and being unassertive
• Loss Theory
• Bowlby-Loss during childhood predisposes to
  depression, esp. another loss

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TREATMENT FOCUS Cognitive Theory

• Core beliefs How you think about your situation
• Identify self-defeating thoughts, beliefs
• Change beliefs and you will change your behavior
• (Review p. 35, 43-45)

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Treatment Efficacy

• Depression very treatable disease
• Episodes usually last 6 to 9 weeks
• Endogenous no identifiable trigger or event
  tx medications with psychotherapy
• Exogenous identifiable event(s) or stressor(s)
  tx counseling/psychotherapy may be enough to
  resolve symptoms

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Nursing Dx For Depressive Disorders

• Alteration in Nutrition Less than body
  requirements
• Sleep pattern disturbance
• Self care deficit
• Alterations in perceptionHallucinations
• Alteration in thought process Delusions
• Potential for Violence directed at self,
• or Risk for Suicide

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Nursing Care and Milieu Management

• Safety First The milieu or environment should
  keep the client safe
• Check all clients every 15 minutes
• Locked environment
• Remove all harmful items
• Mirrors, pocket knives, razors, shoelaces,
  hangers, etc.

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Milieu Management, contd

• Balance Sleep/activity
• Assess hours of sleep
• Encourage exercise/Walking
• Relaxation tapes
• Medication as needed for sleep

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Nursing Care and Milieu Management

• Monitor and Provide Adequate Nutrition
• Observation of client during meals
• Record weight lt weekly
• Record amount eaten
• Vital signs
• Lab work
• A low albumin level or total protein will let
  you know the client has not been eating well

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Nursing Care, Milieu, contd

• Decrease Isolation
• Approach is firm kindness and being direct
• It is time for our 1-1 (or Art Class or Coping
  Skills Group, etc.)
• Listen and Acknowledge Negative Feelings
• Acknowledge even the most negative or suicidal
  feelings. You do not agree with them, but you let
  them know you hear them.

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What Will the Nurse Say?

• Client What Ive done to my family cant be
  fixed, and its all my fault.
• Client Why are you trying to keep me alive? You
  should just let me get it over with.

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Interventions for Other Issues

• Anger writing, discussing, and exercise and . .
  .
• Agitated depression walk with patient and . . .
  .
• Simple, structured activities best in early
  treatment (why?)

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Group Therapies

• Assertiveness training
• Coping Skills
• Grief group
• Art therapy
• Insight oriented psychotherapy (outpatient)
• Family therapy

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Nurse-Client Communication

• Establish trust
• Show sincere concern
• Assess clients negative
• self-talk
• Provide another point of view
• Do not attempt to reason
• Dont reinforce delusions
• May be resistant to come to 1-1
• Active listening, non-directive style

• Cognitive Therapy Strategy
• Have client list 3 negative thoughts about self
• This must be limited in number or could initiate
  rumination
• Have client list 3 positive qualities about self
• Talk with client about positive qualities
• Goal to begin to replace negative thinking with
  more positive thoughts

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Medications

• Antidepressants
• Tricyclics (TCAs)
• Serotonin re-uptake Inhibitors /SSRIs
• Monoamine Oxidase Inhibitors (MAOIs)
• Atypical/Novel Antidepressants (SNRIs, NDRIs, and
  receptor antagonists)
• See Chart in Keltner pp. 236-237 5th ed.
• pp. 182-183 6th ed.

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Other Medications Used for Depression

• Antianxiety medications
• Atypical Antipsychotics
• Psychostimulants
• OTC meds
• St. Johns Wort (hypericum)--herbal remedy
• SAM-e natural remedy, generally considered safe

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Comparison of Modes of Action

• Tricyclics
• a) Non-selectively inhibit reuptake of serotonin
  and norepinephrine
• b) Increase receptivity to serotonin and
  norepinephrine
• SSRIs Selective inhibition of serotonin
  reuptake ? fewer side effects

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Tricyclics (TCAs)

• amitriptyline - Elavil
• desipramine - Norpramin
• imipramine - Tofranil
• Nortriptyline - Pamelor, Aventyl
• clomipramine - Anafranil (most often used for
  OCD, not depression)

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Selective Serotonin Reuptake Inhibitors (SSRIs)

• citalopram - Celexa
• escitalopram - Lexapro
• fluoxetine - Prozac
• fluvoxamine - Luvox
• paroxetine - Paxil
• sertraline - Zoloft

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Antidepressant Side Effect Profiles

• SSRIs
• Nausea, diarrhea,
• GI upset
• Nervousness, anxiety
• Insomnia
• Sexual dysfunction
• Headache
• Slow onset 2-4 weeks
• This length of time is a consideration if client
  is suicidal
• Low OD risk

• TCAs
• Dry mouth
• Blurred vision
• Constipation
• Sedation
• ? appetite?wt gain
• Postural hypotension
• Cardiac effects
• Can be cardiotoxic
• EKG prior to starting
• Slow onset 2-4 weeks
• Overdose potential

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Legal/Ethical Issue SSRIs and Suicide

• Activating effects of some SSRI medications
  (fluoxetine/Prozac and sertraline/Zoloft appear
  to be implicated in increased suicidal behavior
  (to be discussed in suicide lecture)

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Client Teaching Managing Common Medication Side
Effects

• Orthostatic Hypotension
• Teach the patient to rise slowly
• Insomnia
• Schedule dose early in day
• Dry mouth
• Hydrate
• Hard candy or gum
• Drowsiness
• Schedule dose at night
• Cardiac effects
• Tricyclics may be supplied one week at a time

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Serotonin Syndrome

• A potentially fatal syndrome
• Too much serotonin
• Results from Combination of therapy
• Serotonin Reuptake Inhibitors combined with
• Prescribed
• Tricyclic Antidepressants
• Monoamine Oxidase Inhibitors
• Lithium
• Over the Counter Medications
• Cough and cold meds.
• Diet drugs
• St. Johns Wort
• Other
• LSD, Ecstasy

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Serotonin Syndrome, contd

• Symptoms
• CNS-confusion
• Agitation
• Hypomania
• Myoclonus
• Tremor
• Hyperreflexia
• Autonomic signs
• Fever
• Tachycardia OR bradycardia
• Hypertension OR hypotension
• Diaphoresis, diarrhea
• Severe dehydration can be fatal

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Serotonin Syndrome
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Other AntidepressantsMonoamine Oxidase
Inhibitorsand Atypical Antidepressants
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Monoamine Oxidase Inhibitors (MAOIs)

• Inhibit enzyme that breaks down serotonin and
  norepinephrine
• Non-Selective (older) and Selective types
• Usually last choice of pharmacotherapy

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MAOIs

• Nonselective
• phenylzine - Nardil
• tranylcypromine - Parnate
• Selective
• moctobemide - Manerex
• selegiline - Emsam

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Side Effects of MAOIs

• MAOIs can cause very serious hypertensive crisis
• Client must be instructed not to drink red wine,
  beer, eat aged cheese, yogurt, pickled foods,
  sausage, etc. anything fermented/preserved
  Tyramine is chemical ingredient.
• Check with MD before taking any new meds.

• AVOID

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Atypical/Novel Antidepressants

• Selectively prevent reuptake of specific
  neurotransmitters, e.g.
• Serotonin and Norepinephrine (SNRI)
• Norepinephrine and Dopamine (NDRI)
• Norepinephrine only (NRI) add to your outline
• or are
• Receptor Antagonists - increase activity of
  neurotransmitters

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Side Effects of Atypicals

• trazodone/desyrel- Usually used for sleep rare
  side effect priapism
• buproprion/Wellbutrin (SDRI) seizures at high
  doses, irritability, decreased appetite,
  worsening of tics
• venlafaxine/Effexor (SNRI) Nausea, agitation,
  headache and increase in blood pressure
• mirtazapine/Remeron (tetracyclic) Sedation,
  increased appetite
• duloxetine/Cymbalta (SNRI) GI probs., wt. loss

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Some Newer Medications for Depression (NOT ON
TEST!)

• SNRI
• desvenlafaxine - Pristique
• Norepinephrine reuptake inhibitor (NRI)
• reboxetine - Edronax
• Sigma receptor agonist
• opripramole - Insidon, Pramolan
• Rapid acting medications (few hrs-few days)
• Scopolamine, ketamine (not approved)

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Other Medications

• Used in conjunction with an antidepressant for
  treatment of variants of depression e.g.
  agitated-type depression, or for treating
  anxiety, psychosis or severe cognitive symptoms

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Somatic Therapy Electroconvulsive Therapy (ECT)

• Beneficial for for Clients with
• Severe Depression
• Depression that is resistive to treatment with
  medications
• Older adults
• Renal disease or liver disease
• With increased blood serum levels of medication

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ECT, contd

• ECT seems to balance dopamine and serotonin
• Under supervision of anesthesiologist
• Pre-op Give atropine, barbiturate, muscle
  relaxant
• Procedure Induction of seizure via electrical
  current
• Side effects- short term memory loss
• Initially memory of events immediately prior to
  procedure
• Treatment series of 6-10 times
• Spaced several days apart
• After treatment monitor LOC, orientation,
  vitals, resp.
• Client may have immediate relief of depression